397002923-4-26-2022-27-AS-CYAG-CDUN6X-20220426101150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002923
Report Date: 04/14/2022
Date Signed: 04/26/2022 10:11:54 AM

Document Has Been Signed on 04/26/2022 10:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	REMOLONA FAMILY GUEST HOME		FACILITY NUMBER:	397002923
ADMINISTRATOR:	NORA REMOLONA		FACILITY TYPE:	740
ADDRESS:	360 BUTTON AVENUE		TELEPHONE:	(209) 823-9122
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	15	CENSUS: 15	DATE:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jon and Nora Remolona		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit conducted on 04/14/2022 by Licensing Program Analyst (LPA) Charlie Yang out to this facility and was met by the facility designated Administrators, Jon and Nora Remolona, who were briefly interviewed. It was learned that there were currently (5) residents under the care of home health and (3) residents under the care of hospice. This facility has a hospice waiver for (6) residents at any given time. Tour of the facility was conducted. Kitchen area was toured. Drawers and cabinets were reviewed for adequate supply of cook ware, dinnerware, and items essential for resident use. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. Additional food storage units were observed to be present and in use at this time. Medication cabinet, located adjacent to kitchen area, was reviewed. Medication policies and procedures were discussed with facility designated Administrator Nora Remolona. A sample review of the resident medication administration records was conducted as well. First aid kit was observed to be present and contained all of the required components at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. A sample review of the (9) total resident bedrooms was conducted. Resident furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A sample review of the (3) facility restrooms was conducted. Grab bars were observed to be present and in good working order at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closets were observed to contain a sufficient supply of linens, blankets, and towels sufficient to meet the needs of the residents at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 11/16/2021 by Armor Fire Extinguisher Company and in compliance at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: REMOLONA FAMILY GUEST HOME	FACILITY NUMBER: 397002923
	VISIT DATE: 04/14/2022

NARRATIVE

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Laundry area, located as part of the garage, was toured. Detergents and bleach supplies were observed to be locked and made inaccessible to the residents at this time.
Garage area was toured. It was observed to be used as a storage unit for furniture and items for this facility at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
The following forms were requested by this LPA to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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